Alaska WIC Breast Pump Loan & Release Agreement
WIC Clinic______
The WIC Program is extremely pleased with your decision to provide your infant with breast milk. In order to borrow a pump or be issued a single-user pump, you must agree to abide by this Loan and Release Form Agreement.
WIC Participant Information
Date:______SSN:______Infant’s DOB:______
Name:______Email Address ______
Last First
Mailing Address______City______Zip______
Residence Address______City______Zip______
Home Phone# ______Cell______Work______
Additional Contact Person’s Name ______Email Address ______
Mailing Address______City______Zip______
Home Phone# ______Cell______Work______
Breast Pump Issued Pump Serial Number OR State Tag Number
q Electric Breast Pump ______
q Pump In Style ______
Reason for Issuance: Back to Work/School Increase Milk Supply NICU Other
Check as appropriate:
q For Single User Electric Pumps Only: I understand that I will be issued only one single-user electric pump while on the Alaska WIC Program. I understand that I should not loan out or sell this pump.
q I have received and understand instructions for operating this breast pump including how to properly close the case. I am able to operate this breast pump without assistance.
q I have inspected this breast pump and agree that it is in good condition.
q I have received and understand instructions for cleaning this breast pump.
q I agree to follow the instructions for operating and cleaning this breast pump.
q I understand that the WIC Program, or its representatives, cannot be held responsible for any personal damage caused by the use of this breast pump. I release the WIC Program from any liability regarding my use of this breast pump.
q I understand this breast pump is a loan from the WIC Program, and that it is loaned to me on a priority basis. I may be required to return it for use by a higher priority WIC participant. I agree to return the breast pump on (date)______or sooner, if requested or if I am not using it on a daily basis.
q I understand that I must return the breast pump undamaged and clean or be subject to a financial penalty of $350.00. If I don’t return the loaned electric breast pump, the state may use other types of legal options to collect payment, including small claims court, which could result in Permanent Fund Dividend (PFD) garnishment.
q I understand that this breast pump must not be removed from the local area without special permission.
Our supplies are limited so please return the breast pump, when you no longer need it. THANK YOU.
The WIC Program reserves the right to schedule monthly appointments, call you to check on the pump and may issue vouchers on a monthly basis while the pump is on loan.
______
WIC Participant Signature Date WIC Representative Signature Date
Breast pump Returned Date ______